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Friday, June 19, 2015

Caution: this list does not reflect 'quality', or 'best' unless you assume that a lot of people citing and criticising obviously flawed content published in a journal would demonstrate that that journal is a high quality outlet. All it does is indicate how frequently articles in that journal were cited over a predetermined period of time. It doesn't tell us anything about the reasons for the citations. I included journals I found in JCR's medical ethics as well as its ethics list. - Not that it should matter, but for the sake of it, I co-edit 2 and 6 on this list.

Friday, June 05, 2015

I recently came across this piece by an Australian psychiatrist, John Buchanan, published in Australia's only quality broadsheets, Melbourne's The Age and Sydney's Sydney Morning Herald. Much as I am flattered by being described in Australia as an influential bioethicist, he got it badly wrong in his commentary. Here's a reply to Buchanan's analysis (I did, of course, send it to the paper's OpEd editor but didn't receive so much as an acknowledgment that they received it, much less do they apparently want to publish this response - so far for the influential bioethicist thing :-).

John Buchanan argued in this paper (May 27) that Victoria’s
Parliament should reject a motion by the Greens to review the state’s assisted
dying prohibitions. His main concern is that assisted dying legislation could
not protect against abuse. Buchanan is primarily worried about assisted dying
legislation’s impact on disabled patients, the mentally ill, and other
vulnerable people.

As an Australian making a living as an academic in Canada I
have been privileged to chair on behalf of the Royal Society of Canada an
international expert panel drafting a report
on end-of-life decision-making. Among our recommendations was that Canada
ought to decriminalise assisted dying. In
a unanimous decision the country’s Supreme Court came recently to the same
conclusion. On the face of it, it is quite unlikely that the expert panel that
I chaired as well as the honourable Supreme Court justices would have missed
existing evidence of the abuse of vulnerable people in jurisdictions that have
decriminalised.

This perhaps is a good indication as any, that doomsday
sayers such as Buchanan have got it wrong on this issue. His arguments are all
too familiar to those of us who have been involved in these debates. Let me address
some of them.

Among his evidence is a reference to a Dutch ‘medical
ethicist’ who changed his mind on euthanasia. Said ethicist’s views are
presented as a quote from a notorious British newspaper not known to feature
quality content. It turns out, this ‘medical ethicist’ is Theo Boer, a Christian
theologian employed at a Dutch Protestant university. Boer cuts a pretty lonely
figure on this issue in the Netherlands. The existing assisted dying regime is
overwhelmingly supported both by Dutch clinicians as well as the Dutch people. Clutching
at straws is a familiar theme when it comes to anti-choice activism.

Buchanan serves another staple of anti-choice campaigners,
personal anecdotes. He mentions hospital administrators getting all fired up
about assisted dying so that they can empty hospital beds. There’s naturally
also a fair bunch of greedy relatives and whatnot else. It is odd indeed that
we must take his word for it. In a case currently windings its way thru the
courts in New Zealand, similar anecdotes have been presented by the handful of
clinicians travelling the globe to prevent legal assisted dying from coming
about. Unsurprisingly, actual peer reviewed scientific literature does not
support these claims. Perhaps anti-choice campaigners are drawn in strange ways
to abusive hospital administrators and greedy relatives. A
recent survey of permissive jurisdictions concluded that the average
patient requesting assistance in dying is a late-stage middle-class male cancer
patient. At no time has it been demonstrably shown that in permissive jurisdictions
vulnerable disabled or mentally ill patients have been disproportionately
affected by assisted dying. If anything, the existing evidence could be
interpreted as showing that they have trouble accessing assisted dying.

There is something deeply troubling about the trope of alleged
abuse meted out against disabled people, beyond the mere absence of credible evidence
to support it. Disabled people have often been at the forefront of attempts to
decriminalised assisted dying, because they often are least able to end their
lives on their own accord, precisely due to their disability. A
case in point is Canadian Steven Fletcher, a quadriplegic Conservative Member
of Parliament. Paralysed from his neck down, a result of a car accident
involving a moose in 1996, it was Fletcher who introduced assisted dying
legislation in the Canadian House of Commons.

Buchanan also claims darkly that Belgium and the Netherlands
have widened access criteria. For that to be of concern we would already need
to have concluded that there is something wrong about assisted dying. That,
however, is what is in dispute. If I lived in a jurisdiction that had
decriminalised assisted dying, I would want my government to monitor carefully
how the existing regime works out and to adjust it in response to societal
need. That might well entail changes to access criteria. Any such change as
such is not evidence of something gone awry.

Buchanan further makes the suggestion that we should improve
the quality and availability of palliative care. He is right, we suggested that
much in our Canadian report. He is wrong to assume that this is an either-or
type situation. We know that even with the best palliative care there will be a
fair number of patients who want an assisted death regardless. Study after
study produced by palliative care specialists opposed to assisted dying comes
to this very same conclusion. Palliative care will never be a panacea to
resolve everyone’s suffering to their satisfaction.

Buchanan ends with the conclusion that ‘the risks of
assisted suicide legislation are too great.’ His whole piece provides no
evidence to support that conclusion. The problem for Buchanan and others like
him is that we do not live in the 1970s any longer. We actually know what
happened over many years in jurisdictions that have introduced assisted dying.
Precisely the lack of evidence of abuse is the reason for why an increasing
number of jurisdictions are decriminalising assisted dying. It is time for
Australia to follow suit. Leaving things as they are condemns many of us to a
death that is disrespectful of our final considered choices.